My Action Plan

Date: _____________

I _________________________________________ and _________________________________________ have agreed that to improve my health I will:
   (patient identification number)                                                   (name of clinician)

1. Choose one of the activities below:

______ Work on something that's bothering me: ______________________

______ Stay more physically active!

______ Take my medications.

______ Improve my food choices.

______ Reduce my stress.

______ Cut down on smoking.

2. Choose your confidence level:

This is how sure that I am that I will be able to do my action plan:

10. Very Sure
5. Somewhat Sure
0. Not Sure At All

3. Complete this box for the chosen activity:

What: _______________________________________________________________

How much: _______________________________________________________________

When: _______________________________________________________________

How Often: _______________________________________________________________

Sex: M or F

Age: ______

Hispanic: Yes or No

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